TürkçeDiaphragm paralysis is the loss of the diaphragm’s ability to contract due to damage to the phrenic nerve or deterioration of the muscle itself. The diaphragm is the primary respiratory muscle separating the chest cavity from the abdominal cavity. This condition prevents the lungs from expanding adequately, resulting in significant breathing difficulties. Most commonly developing after surgical procedures, tumors compressing the phrenic nerve, or neurological disorders, diaphragm paralysis typically presents with shortness of breath and a marked decline in quality of life. Thanks to modern thoracic surgery techniques and innovative treatment approaches, the goal is to permanently restore patients’ breathing comfort and enable them to safely return to their normal daily activities.
What Is Diaphragm Paralysis?
To understand the body’s breathing mechanism, the diaphragm can be compared to a flexible dome. Even while at rest, this muscle performs the majority of the body’s respiratory workload on its own. Whenever we inhale, the diaphragm contracts and flattens. This movement creates a vacuum-like effect inside the chest cavity, drawing fresh air into the lungs.
The regular and rhythmic contraction of the diaphragm is controlled by the phrenic nerve, which originates in the cervical spinal cord and travels downward through the chest to reach the diaphragm. When transmission through this nerve is disrupted, the diaphragm becomes unable to function. Anatomically, the diaphragm consists of two separate domes, one on the right and one on the left. Since the liver occupies the right side of the abdomen, the right diaphragm naturally sits slightly higher than the left. This normal height difference is always taken into account during radiological examinations. When this primary engine of respiration becomes paralyzed, patients struggle to take deep breaths, feel unable to fully inflate their lungs, and experience impaired oxygenation throughout the body.
What Other Diaphragm Disorders Can Occur Besides Diaphragm Paralysis?
The diaphragm may also be affected by structural weakness or herniation in addition to paralysis. There is normally a pressure difference between the abdominal cavity and the chest cavity, with abdominal pressure generally being higher. When a congenital weakness or an acquired tear develops in the diaphragm, abdominal organs may migrate upward into the chest cavity.
Some of the major diaphragm disorders encountered in thoracic surgery include:
- Bochdalek hernia
- Morgagni hernia
- Hepatic hydrothorax
- Catamenial pneumothorax
- Eventration
Each of these disorders has its own unique mechanism of development. For example, Bochdalek hernia is typically a congenital defect that occurs on the left side and presents during infancy. Morgagni hernia, on the other hand, is more commonly seen in adults, particularly those who are overweight, usually on the right side, and may cause cramp-like abdominal pain or digestive problems.
Hepatic hydrothorax develops in individuals with liver disease when abdominal fluid passes through tiny defects in the diaphragm into the chest cavity. Catamenial pneumothorax is a condition primarily affecting women, occurring in association with the menstrual cycle and characterized by chest pain related to cellular deposits on the diaphragm. Eventration refers to thinning and upward stretching of the diaphragm despite an intact phrenic nerve.
What Are the Main Causes of Diaphragm Paralysis?
Damage to the structure or function of the phrenic nerve, which controls diaphragmatic contraction, is the primary cause of diaphragm paralysis. Since this nerve travels from the neck, alongside the lungs and heart, before reaching the diaphragm, its long course makes it vulnerable to injury.
Conditions that may cause phrenic nerve injury include:
- Cardiac surgery
- Lung surgery
- Neck surgery
- Blunt trauma
- Sports injuries
- Tumor compression
- Neurological disorders
During coronary artery bypass surgery or lung resections, the nerve may be affected by manipulation of surrounding tissues. Stretching, traction, or heat generated by surgical instruments may impair nerve conduction. Likewise, motor vehicle accidents or severe shoulder injuries can damage the nerve.
Tumors or enlarged lymph nodes growing within the chest or neck may physically compress the phrenic nerve and interrupt signal transmission. Neurological diseases such as Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS), which affect the body’s motor nerves, may also contribute to the condition. In some patients, however, no identifiable cause can be found despite extensive evaluation. These cases are classified as idiopathic diaphragm paralysis and are often attributed to temporary or permanent nerve damage following an unnoticed viral infection.
What Symptoms Are Seen in Patients with Diaphragm Paralysis?
The severity of diaphragm paralysis depends largely on whether one or both sides are affected and on the patient’s overall lung health. While unilateral paralysis causes a moderate reduction in breathing capacity, bilateral involvement can lead to much more severe respiratory impairment.
The most common symptoms include:
- Shortness of breath
- Easy fatigue
- Palpitations
- Sleep apnea
- Morning fatigue
- Shoulder pain
- Pain at the base of the neck
Symptoms become particularly noticeable during physical activity. Sudden shortness of breath while climbing stairs, walking uphill, or exercising is among the most frequent complaints. However, many patients experience their greatest difficulty when attempting to lie flat in bed.
This can be understood by considering the effects of gravity. When standing, gravity pulls abdominal organs such as the stomach, liver, and intestines downward. When lying flat, this support disappears, allowing these organs to push upward against the weakened, paralyzed diaphragm and further compress the lungs. As a result, patients often report that they cannot sleep flat and instead require several pillows or even sleep in a sitting position.
Stimulation of the affected phrenic nerve may also produce referred pain in the shoulder or neck. Effective coughing depends on strong diaphragmatic contraction. When the diaphragm cannot contract properly, patients are unable to cough forcefully, leading to mucus retention, airway obstruction, and recurrent lower respiratory tract infections such as pneumonia. Interrupted breathing during sleep and waking up feeling unrefreshed are also common complaints.
Which Radiological and Functional Tests Are Used to Diagnose Diaphragm Paralysis?
When diaphragm paralysis is suspected in a patient presenting with shortness of breath, the evaluation begins with a detailed medical history and physical examination, including auscultation of the lungs. Breath sounds are typically diminished on the affected side. Several specialized imaging and functional studies are then used to confirm the diagnosis.
The primary diagnostic methods include:
- Chest X-ray
- Fluoroscopy
- Computed tomography (CT)
- Ultrasonography
- Magnetic resonance imaging (MRI)
- Pulmonary function tests
- Electromyography (EMG)
A standard chest X-ray often reveals elevation of the affected hemidiaphragm. However, an elevated diaphragm does not always indicate paralysis, making assessment of diaphragmatic motion essential. This is accomplished using fluoroscopy during the “sniff test,” in which the patient is asked to take rapid, sharp breaths through the nose. A healthy diaphragm descends abruptly during inspiration, whereas a paralyzed diaphragm paradoxically moves upward because of negative pressure within the chest. This paradoxical movement is a key diagnostic finding.
Computed tomography provides detailed visualization of the chest anatomy and helps identify masses compressing the phrenic nerve. Ultrasound allows radiation-free evaluation of diaphragmatic thickness and movement. MRI may be used when cervical spine or spinal cord pathology is suspected.
Pulmonary function testing objectively measures the impact of the condition on breathing capacity. A marked reduction in lung function while lying down is considered a characteristic finding. Finally, electromyography (EMG) assesses the electrical activity of the phrenic nerve and helps determine both the severity of nerve injury and its potential for recovery.
How Is the Decision Made to Perform Surgery for Diaphragm Paralysis?
When diaphragm paralysis is diagnosed in an adult, the first consideration is how significantly the symptoms interfere with daily life. Surgical treatment is considered if breathing difficulty reduces quality of life, prevents comfortable sleep while lying flat, and pulmonary function tests demonstrate a substantial reduction in lung capacity.
The upward displacement of a paralyzed diaphragm compressing the lung is fundamentally a mechanical and anatomical problem. Medications, bronchodilator inhalers, or nebulizer treatments cannot restore a weakened, elevated diaphragm to its normal position. The nonfunctional muscle must be mechanically repositioned to create sufficient space for lung expansion. For this reason, surgery remains the most effective long-term treatment.
What Is Diaphragm Plication Surgery?
The standard surgical treatment for symptomatic diaphragm paralysis or eventration is known as diaphragm plication. This procedure can be compared to tightening a loose drumhead or pulling down a parachute that has billowed upward. The relaxed diaphragm has stretched upward and must be repositioned.
The primary benefits of the operation include:
- Increased lung volume
- Reduced shortness of breath
- Improved sleep quality
- Greater exercise tolerance
During surgery, the surgeon folds the weakened diaphragm upon itself using specialized suturing techniques, pulls it downward, tightens it, and secures it in its normal anatomical position. This recreates the chest cavity space necessary for full lung expansion. Pressure balance within the thoracic cavity is restored, resulting in significant improvement in respiratory performance.
The procedure is performed under general anesthesia using specialized endotracheal tubes that allow one lung to be ventilated while the other is temporarily collapsed to provide optimal surgical exposure. A nasogastric tube is inserted to decompress the stomach, reducing pressure on the diaphragm and minimizing the risk of gastric injury during suturing. Because the diaphragm moves continuously during breathing, durable non-absorbable sutures are used. Small Teflon pledgets are placed beneath the sutures to prevent tearing through the muscle tissue. In patients with extremely thin diaphragms, synthetic mesh reinforcement may also be added to strengthen the repair.
What Are the Advantages of Minimally Invasive and Robotic Surgery for Diaphragm Paralysis?
In the past, thoracic surgery required large incisions along the side of the chest and spreading of the ribs. These traditional approaches often resulted in prolonged recovery and significant postoperative pain. Today, advances in medical technology allow diaphragm repairs to be performed using minimally invasive techniques with much greater patient comfort.
The key advantages of minimally invasive and advanced surgical techniques include:
- Small surgical incisions
- Less postoperative pain
- Shorter hospital stay
- Faster return to daily activities
- High-definition visualization
In Video-Assisted Thoracic Surgery (VATS), instead of making a large incision, high-definition cameras and long, slender surgical instruments are introduced through small openings between the ribs. Since rib spreading is unnecessary, postoperative pain is significantly reduced. In the even more advanced Uniportal VATS technique, the entire procedure can be completed through a single small incision.
Robotic surgical systems, such as the Da Vinci platform, represent one of the latest technological advances. They provide surgeons with highly magnified, three-dimensional visualization even within the narrowest areas of the chest. The surgeon controls robotic arms from a console, eliminating natural hand tremor while allowing a greater range of motion than the human wrist. This enables exceptionally precise and secure placement of sutures. Compared with open surgery, patients undergoing minimally invasive or robotic procedures are typically discharged much sooner and return to their normal activities more quickly.
Which Patients Are Suitable Candidates for Diaphragm Pacing in Diaphragm Paralysis?
In diaphragm paralysis, the problem does not always lie within the muscle itself or the portion of the phrenic nerve located inside the chest. In some patients, both the diaphragm muscle and the phrenic nerve remain anatomically intact, but the breathing signal from the brain or upper spinal cord cannot reach the nerve. In such situations, diaphragm pacing is considered as an alternative to diaphragm plication.
Patient groups in whom diaphragm pacing may be considered include:
- Cervical spinal cord injuries
- Sleep apnea and hypoventilation syndromes
- Early-stage motor neuron diseases
The diaphragm pacing system functions similarly to a cardiac pacemaker. Electrodes connected to a small pulse generator are placed either directly onto the phrenic nerve or into the diaphragm muscle itself through the abdomen. The device delivers regular low-voltage electrical impulses that mimic the body’s natural breathing rhythm, causing the diaphragm to contract and descend.
This approach offers tremendous hope for patients who require long-term mechanical ventilation because of cervical spinal cord injuries sustained in motor vehicle accidents or falls. Successful diaphragm pacing may allow these individuals to become independent of the ventilator, enabling speech, improving mobility, and significantly reducing the risk of serious ventilator-associated infections. Before implantation, however, testing must confirm that both the phrenic nerve and diaphragm muscle still respond to electrical stimulation.
What Is Recovery Like After Diaphragm Paralysis Surgery?
Recovery following diaphragm surgery is carefully monitored and managed. At the end of the procedure, a chest drain is inserted to remove any air or fluid that may accumulate within the chest cavity.
Important aspects of postoperative recovery include:
- Chest drain management
- Regular walking
- Breathing exercises
- Proper nutrition
- Avoiding heavy lifting
During the first few postoperative days, chest X-rays are obtained to confirm complete lung expansion. Once the lung has fully re-expanded and drainage decreases sufficiently, the chest tube is removed comfortably. When normal digestive function returns, patients gradually resume oral intake beginning with liquids and soft foods. Easily digestible foods are recommended for several days to minimize gas-related discomfort around the diaphragm.
Early mobilization plays a major role in restoring lung capacity. Patients are encouraged to begin short walks in the hospital corridor as early as the day after surgery. They are also provided with incentive spirometers (Triflo devices) to perform regular breathing exercises that promote lung expansion and reduce the risk of postoperative infection. Sitting upright rather than remaining flat in bed throughout the day is also recommended because it reduces pressure on the diaphragm.
During the first several weeks after discharge, patients should carefully avoid heavy lifting, excessive physical exertion, and activities that involve significant straining. These precautions are essential to allow the surgical repair to heal securely and completely.
Frequently Asked Questions
Prof. Dr. Alper Fındıkcıoğlu graduated from Istanbul University Faculty of Medicine and completed his thoracic surgery residency at Dr. Siyami Ersek Hospital. He began his academic career at Başkent University in 2005; he received the title of associate professor in 2014 and professor in 2022. He has extensive experience in lung cancer, chest wall diseases, and minimally invasive surgery. Since 2024, he has been continuing his professional work at Acıbadem Hospital.
